Thank you all to those that gave me your input.
I did not provide an extensive biomechanical exam
with my first presentation. This patient has at
least 10 degrees of ankle dorsiflexion with her
knee extended or flexed. Her hamstrings are not
tight. She has symmetrical hip motion more with
no internal position. There is no internal tibial
torsion. She does not have ligamentous laxity.
Her first ray is stable on exam. She is only
moderately pronated in stance and gait. Her
lateral x-ray does not have an anterior break in
the cyma line. There is no Kirby's sign. There is
no elevation of 1st ray (Seeberg's index).
She has noticed the bunions for several years,
and has had moderate aching in the joint for the
past year. She is a serous athlete. Although she
is only 12, she has reached menarche and her
appearance is that of several years older. I tell
all my patients that these are progressive
deformities and that there is a high rate of
reoccurrence, especially in a young patient. I
always recommend orthotics, both before and after
a surgical approach.
On radiographs her growth plates are almost
closed. I suspect there is very little additional
length of her metatarsals to come. I do not
believe that she will "escape" surgery in her
life time. Perhaps if not surgery this year than
next. She is living at home and has the summer
off. She does not have a job and is in a
protective environment. Should we wait until she
has to make sacrifices both socially and
academically to deal with this? Do we wait until
she is in college or has a job that put stress on
the either living with the deformity or the
stress of the surgical recovery?
With a 25 degree met adductus angle and a 15 IM,
the true 1st IM is closer to 25. Do I do a head
procedure or base or tight rope? again, perhaps
not this year, but maybe next.
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